Anxiety is estimated to occur in up around 10% of patients diagnosed with cancer, [1] in one third with heart disease, and two thirds of those with chronic obstructive pulmonary disease or with renal disease. [2] It can be a response to impending death, but may result from other untreated conditions or symptoms.

Anxiety: the palliative context

  • Untreated pain
  • Untreated or poorly managed symptoms
  • An underlying anxiety disorder (e.g. panic disorder, phobia)
  • Fear of death
  • Family distress
  • Drug induced.

Important contributing factors

  • Previous psychiatric history
  • Alcohol and nicotine dependence
  • Long term benzodiazepine use
  • Loss of control - real or perceived.

Key messages

  • Anxiety may be a result of an underlying anxiety disorder, untreated pain, or other untreated or poorly managed symptoms. [3,4]
  • Anxiety and anxiety disorders frequently co-exist with depression. [5,6]
  • A structured clinical interview is considered the ‘gold standard’ approach to detecting anxiety disorders.
  • Related concerns at the end of life include:
    • a sense of burden
    • loss of dignity
    • a desire for death. [7]
  • There are pharmacological agents in use for patients at the end of life. [7] However, as yet there is no evidence from randomised controlled trials as to their effectiveness in a palliative population. [8]
  • Mindfulness based therapies have been studied in a meta-analysis which suggests that these may significantly reduce symptoms of anxiety and depression. [9]

Active research areas / controversies

  • The most widely used screening tool for anxiety is the Hospital Anxiety and Depression Scale (HADS) which has separate scales for depression and anxiety and enables the course of anxiety symptoms to be monitored over time. Concerns as to its sensitivity and specificity have been raised. [10-13]
  • Given there is insufficient evidence to draw a conclusion about the effectiveness of pharmacotherapy for anxiety in terminally ill patients prospective controlled clinical trials are needed. [8]
  • Death anxiety in older adults is shedding insight into the relationship of anxiety at the end of life. [14-16] Findings to date indicate that lower ego integrity, more physical problems, and more psychological problems are predictive of higher levels of death anxiety in elderly people.

PubMed Searches

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  1. Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol. 2011 Feb;12(2):160-74. Epub 2011 Jan 19.
  2. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006 Jan;31(1):58-69.
  3. Stiefel F, Razavi D. Common psychiatric disorders in cancer patients. II. Anxiety and acute confusional states. Support Care Cancer. 1994 Jul;2(4):233-7.
  4. Miller K, Massie MJ. Depression and anxiety. Cancer J. 2006 Sep-Oct;12(5):388-97.
  5. Massie MJ, Holland JC. Depression and the cancer patient. J Clin Psychiatry. 1990 Jul;51 Suppl:12-7.
  6. McCarthy M, Lay M, Addington-Hall J. Dying from heart disease. J R Coll Physicians Lond. 1996 Jul-Aug;30(4):325-8.
  7. Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006 Jun;9(3):751-72.
  8. Candy B, Jackson KC, Jones L, Tookman A, King M. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev. 2012 Oct 17;10:CD004596.
  9. Piet J, Würtzen H, Zachariae R. The effect of mindfulness-based therapy on symptoms of anxiety and depression in adult cancer patients and survivors: a systematic review and meta-analysis. J Consult Clin Psychol. 2012 Dec;80(6):1007-20. Epub 2012 May 7.
  10. Lloyd-Williams M. Screening for depression in palliative patients: a review. Eur J Cancer Care (Engl). 2001 Mar;10(1):31-5.
  11. Carey M, Noble N, Sanson-Fisher R, MacKenzie L. Identifying psychological morbidity among people with cancer using the Hospital Anxiety and Depression Scale: time to revisit first principles? Psychooncology. 2012 Mar;21(3):229-38. Epub 2011 Sep 14.
  12. Mitchell AJ, Meader N, Symonds P. Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: a meta-analysis. J Affect Disord. 2010 Nov;126(3):335-48. Epub 2010 Mar 5.
  13. Vodermaier A, Millman RD. Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis. Support Care Cancer. 2011 Dec;19(12):1899-908. Epub 2011 Sep 4.
  14. Fortner BV, Neimeyer RA. Death anxiety in older adults: a quantitative review. Death Stud. 1999 Jul-Aug;23(5):387-411.
  15. Adelbratt S, Strang P. Death anxiety in brain tumour patients and their spouses. Palliat Med. 2000 Nov;14(6):499-507.
  16. Lauderdale SA, Sheikh JI. Anxiety disorders in older adults. Clin Geriat Med. 2003 Nov;19(4):721-41.

Last updated 17 January 2017